CT scan of abdomen and pelvis without contrast Essay

ABDOMEN The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. pinched structures of the stomach appeared unremarkable. No free air was seen. PELVIS Good quality, non contrasted actual CT interrogationination of the pelvis with coronal reconstructions. Prostate, seminal vesicles and urinary bladder appeared WNL. The bowels seen on the study appeared WNL, except for inflammatory changes of the appendix and seccum with acute appendicitis. Osseous structures of the pelvis appeared in tract with evidence of bi askance hip chronic changes. IMPRESSION1. Findings logical with acute appendicitis2. Degenerative changes of the hipsPaula ReddyNNEFDTDISCHAGE SUMMARY persevering get to Benjamin EngelhartPatient ID 112592DOB 10/05/Age 46Sex MDate of Admission 11/14/2012Date of Discharge 11/17/2012Admi tting Physician Benard Kester, MD oecumenic SurgeryProcedures Performed Laparoscopic appendectomy with placement of RLQ run offon 11/14/2012 Complications None.Discharge Diagnosis acute accent subapperative appendectomy perforated. DIAGNOSTIC/IMAGING LABS Lab results at the time of admission showed a WBC count of 13. CT view done in the ED revealed an acute appendicitis with fleggon. HOSPITAL COURSE The 46 years old Caucasian gentleman presented to the ED with a 3 day history of abdominal pain, still in the last 24 hours and it has________ migrated to the RLQ with anneorixia, guarding and elevated WBC of 13 and CT scan consistent with appendicitis. The tolerant was taken to the operating(a)(a) room where he underwent a laparoscopic appendectomy that revealed appendix perforation and phlegmon. The appendix was removed in toto with an intact stable line. A drain was placed in the RLQ referable to the fleggmonous material. Patient did well over the successive 2-3 days postoperat ively with resumption of an oral diet having past flatus with having bowel movement with minimal drain output. However his WBC fr takeed to 6. His drain has been left intact. Patient is being discharged on the post operative day 3 on a 1 week course of PO gentamicin. The drain left in place. The drain will be removed in my office on 11/24/2012 if the drain output is minimal. Patient is on a PO diet. He was given a script for both antibiotics and PO narcotics. (Continued)PLAN institutionalise operative visit in my office in 1 week for evaluation and possible removal of JP drain. No heavy lifting for 4 weeks following surgery. Patient is to complete his full course of post operative antibiotics. DISCHAGE SUMMARYPatient is to report to the ED or my office earlier if any redness or foul smelling drainage out of the wound sit. Any swelling, fever, pain or any other concerns. Patient and his wife verbalized the understanding of the symmetricalness with the above plan.Bernard KesterCC M ax Hirsch, MDD11/14/2012T11/14/2012HISTORY AND PHYSICAL EXAMINATIONPatient appoint Benjamin EngelhartPatient ID 112592DOB 10/05Age 46Date of Admission 11/14/2012Emergency Room Physician Alex McClure, MDAdmission Diagnosis Acute AppendicitisHISTORY OF PRESENT ILLNESS 46 year old gentlemen with past medical history significant only for degenerative disorder with bilateral degenerative disease of the hips. Secondary to arthritis. Presents to the Emergency room after having had 3 days of abdomen pain. It usually started 3 days ago and was generalized vague abdomen complaint. Earlier this morning the pain localized and radiated to the RLQ. He had some nausea without amesis. He was able to tolerate PO earlier around 6am. but presently denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radi ation at this point. He has never had a colonoscopy. PAST MEDICAL HISTORY Significant for arthritis of bilateral hips seen by Dr. Hersch. PAST surgical HISTORY NegativeMEDICATIONS Piroxicam for degenerative joint disease of bilateral hipsALLERGIES No known drug allergiesSOCIAL HISTORY Patient admits alcohol use of goods and services nightly and on weekends. Denies tobacco use and illicit drug us. He is married.FAMILY HISTORY No history of cancer or inflammatory bowel disease in his family.REVIEW OF SYSTEMS12 point ROS was preformed and is negative except noted in above HIP, PMH and PSH. Careful attention was paid to endocrine, integumentary, pulmonary, renal and neurological exam PHYSICAL EXAMINATION Vital Signs. TEMPERATURE 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra eyepiece motions intact. ORAL Shows oral pharynx cl ear but slightly dry mucosal membranes. TMS Clear. NECK Supple, No thrangegally or JVD. No cervical,subclavicular, axilarry or lingual lymphinalpathy. warmness Regular rate and rhythm.No thrills or murmur heard. LUNGS Clear to aspiration bilateral. ABDOMEN Obese with minimal bowel sounds, slightly distended there is RLQ tenderness with guarding and soupcon rebound. Positive _____. Actuator signs with negative psoas side. RECTAL No evidence of blood or masses. PROSTATE WNL. EXTREMITIES No clubbing, cyanosis, clots or edmea. 1+ pedal pulses bilaterally. NUERO Cranial nerves 2-12 grossly intact. DIAGNOSTIC DATA WBC was 13.4, Hemoglobin and hematocrit 15.4 and 45.8, platelets 206 with 89% shift. Sodium 133, Potassium 3.7,Chorlide 99, Bicarbonate 24, BUM and Creatine 18 and 1.1, Lukeuos 146, adermin 4.3, total bulliru,1.7, sleep of the LFTs is WNL. Urinary analysis reveals trace keytones with 100 mg per decimeter with small measuring of blood.CT scan was preformed revealing evidence of acute appendicitis with parasitical firing off as well as facilitation of appendix inflammation and haziness in aperparacifiacal dilation. There is evidence of degenerative joint disease in bilateral hips on the cat scan as well. ASSESTMENT PLAN This 46 year old Caucasian gentleman has signs and symptoms and radiographical findings consistent with acute appendicitis without evidence of abscesses. The plan is to take him to the operating room for laproscopic possible open appendectomy and possible large bowel dissection should the case resisitated. Plan was discussed with patient with his wife. Risk, benefits and alternatives were discussed. There was no barriers to communication and all questions were answered appropatily The patient understands the plan and desires to proceed .(Continued)The plan was discussed with Dr. Keslerof general surgery who agrees and will take patient to operating room .Alex McClure, MDD11/14/2012T11/14/2012PATHOLOGY REPORTPatient Name Benjamin Engelhar tPatient ID 112592 DOB 10/05/Age 46Sex MPathology Report No 10-S-9044Date of Surgery 11/14/2012Attending Physician Bernard Kester, MD general surgeryPreoperative Diagnosis Acute appendicitisPostoperative Diagnosis Necrotizing acute appendicitisSpecimen Received extension other than incidentalDate specimen received 11/14/2012Date reported 11/16/2012CLINICAL HISTORY Acute appendicitis. taxation DESCRIPTION The specimen was received in formily? With patient name, ID and appendix. It consist of a appendix bill 6 x1.51.5 cm there periepdesial fat attached to it measuring 64 by1 cm. The cirrosal surface is hemmoraggric. Upon opening the appendix there is percudent exudates material. The wall thickness measures 0.3cm. Representive sections are present is 1 cassettes. MICROSCOPIC DESCRIPTION PerformedMICROSCOPIC diagnosis Appendix appendectomy, Necrotizing acute appendicitis. ICD Diagnosis Code 540.9(Continued)CPT Code 8-88304Georgia Tamato,MDALWD11/14/2012T11/14/2012OPERTIVE REPORTPatie nt Name Benjamin EngelhartPatient ID 112592DOB 10/05Age 46Sex MDate of Admission 11/14/2012Date of Procedure 11/14/2012Admitting Physician Bernard Kester, MD General SurgerySurgeon Bernard Kester,Assistant Jason Wangner, PACCirculating nurse Jimmy Dale Jet, RNPreoperative diagnosis Acute appendicitis.Post operative diagnosis punch appendicitis.Operative Procedure1 Laparoscopic Appendectomy.2 Placement of RLQ drain.Anesthesia General endotracheal.Specimen Removed 1 Necrotic appendix.IV Fluids 1700 crystalloid.Estimated Blood Loss 10mL. water Output 300mL.Complications None.INDICATIONS This gentleman is a 46 year old Caucasian male that came in with a 3 day history of abdominal pain, however the pain worsened after 24 hours to the RLQ and caused a significant amount of anorixia. He presented to the ER department. CT scan to abdominals and pelvis showed acute appendicitis. Labs showed WBC at 13. Laparoscopic appendectomy procedure was explained along with the risk, benefits and possib le complications. Patient voiced his desire to proceed. Patient was started on preoperative gentamicin. DESCRIPTION OF PROCEDURE Patient was IDd measure 2 in the pre op holding scene of action. A final timeout was held in the nursing area, anesthesia and surgical service during in which the patient ID was confirmed and the surgical invest was initialed. He was given preoperative antibiotics. He was taken back to the OR and placed in the supine position.General endotracheal anesthesia was induced. SEDs were placed on his lower extremities. His Left arm was tucked to the side. Foley Catheter was placed. His abdomen was shaved and prepped with betadine solution, and draped in the usual standard fashion. A small semicircular umbilical incision was make to the subcutaneous tissue down to the fascia. And was gasped at either side and was incised. Kelly clamped was easily inserted. Stay sutures made a _____on either side the Hasson trocar was placed and pneumoperitoneum was easilyachiev ed. 10 mL port was placed in Left abdomen and a 5 mL was placed in the LLQ. Inspection of RLQ showed a significant amount of adhesions and the small bowel trying to wall off perforated appendix. Milky purulent exudates was noted in surrounding area. The small bowel was carefully naked as a jaybird off the RLQ side wall.Fibrous exudate the vermiform appendix was identified. It was neurotic perforated in appearance The cecum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal illium through the pelvis were significant, attempts at this time were not made to free them. There was no evidence of obstruction. The base of the appendix was Identified and dissected and lifted free. Stapler buckram with___ was used to transect the base______however again inflammation extended to the level of the cecum. Though the cecum itself was also inflamed. The remainder of the mesoappendix was divided with a Endo GIA loaded with a _____. Appendix was placed int o a endo catch bag was brought out through the umbilical cord site and sent to pathology for routine processing. Inspection of the RLQ and the area was irrigated coupsuley, there was no further evidence of purulent exudate. The appendicualr stump remained and doesnt appear to be inflamed. However____wasnt bleeding. There was some fibrous exudate in the area.Consequently I felt like we had 2 options, we either perform a right epicolodectomy, given the intent of the adhesions in the pelvis would likely convey a laparotomy or place a drain with antibiotics possibly controlling the fistula until the inflammation resolves. But hopefully it will heal on its own spontatensouly. Consequently we placed a19 French round Blake drain in the RLQ and brought it out through the LLQ in the 5mm port site. It was secured to the skin using a micro suture. Nuenopartiumeum was whence desufflated the fascia of the umbilical port site was closed using a 2,o vicro that had been previously placed. All wou nds were enthsitized using 1/2% marking solution and was coupsley irrigated. kowtow edges approximated using 4 or monocro. The wounds were dressed with beatdine spray and steri strips. Drain sponge was placed around the drain, Foley catheter was removed. The patient was awakened, exubated then taken to recovery PAR in stable condition. Having tolerated the procedure well. No complications were observed. DISPOSISTION1 The patient will be transferred to the floor.2 He will be kept at least overnight.3 He will be taught drain care.4 He will go home with the drain on place.5 He may require a fistulagram in the future.Benard Kester, MDD11/14/2012T11/14/2012